May 19, 2015 Issue

Clinical Practice Points

High breast density increases breast cancer risk and can mask tumors, decreasing the
sensitivity of mammography. This study found that not all women with dense breasts
are at sufficiently high risk for interval cancer to justify consideration of supplemental
or alternative screening methods.

Use this study to:

Review current guidelines. Use another paper in this issue that summarizes and compares the current screening guidelines from
several organizations . Ask your learners what factors increase a woman's risk for
breast cancer. Use the information in ACP Smart Medicine: Screening for Breast Cancer to help prepare.

Ask your learners how they counsel a woman whose screening mammogram reveals extremely
dense breasts or heterogeneously dense breasts. Will the numbers presented in Table
5 influence the approach they may take? How will your learners incorporate patient
preferences into their discussions?

Ask your learners if they know about legislation in 21 states, and being considered
for federal law, that mandates informing women if mammography reveals dense breasts.
Do your learners believe this should be mandatory? How do the findings of this study
influence their thoughts? Read the accompanying editorial. The authors argue that breast density should not be the sole criterion to guide
decisions about supplemental breast imaging because of the resultant high cost and
unclear benefits.

Should informed consent for participants in research that compares the effectiveness
of standard medical practices include notification of the potential risks of those
practices? This survey of 1095 adults examines attitudes about risk and preferences
for notification and consent for such research.

Use this study to:

Start a teaching session with a multiple-choice question. We've provided one below!

Review the elements of appropriate informed consent for any procedure or research
study. Practice with your learners how to use the “Teach Back” method
to ensure patients understand what is being proposed. Observe a learner at the bedside
performing an informed consent conversation and provide feedback.

Ask your learners whether they believe consent should be required for the types of
research described in this study (they're described in the last paragraph of the study's
Methods section on page 692).

Ask your learners to define “research” and why the definition matters. An editorialist points out that our society currently “accepts” that studies not labeled
as “research” do not require consent (e.g., a quality improvement project
within our hospital). Is this OK? Read the editorial and ask your learners if they feel a “Kantian” approach requiring
strict informed consent for all studies is needed to avoid the slippery slope that
leads to the abuse of people, as occurred in the Tuskegee study.

Clinical Guideline

Recommended strategies for cancer screening vary in the intensity of their search
for asymptomatic lesions and in value. This first paper outlines a framework for thinking
about the value of varying intensities of cancer screening and describes how increasing
intensity beyond an optimal level leads to low-value screening. The second paper offers
screening advice for 5 types of cancer, focusing on reaching all eligible persons
with high-value screening options to provide a degree of benefit that justifies the
harms and costs incurred.

Use this study to:

Review with your learners what determines the “optimal” screening intensity.
Use Figure 1 to illustrate the balance of harms and benefits. Use Figure 3 to follow
the course of four patients, illustrating how screening is of benefit for only one
of them.

Ask your learners what “lead-time” bias is. What harms can result from
screening? What do the authors mean when they say that “screening is a cascade
of events”? Why is that important when considering the balance of harms and
benefits?

This issue's featured Annals Archive paper is a 1998 discussion of how military metaphors to describe the “war on breast
cancer” have influenced how we conceptualize the disease and how it should
be approached.

Plan a second teaching session using the second paper to review the patients seen
in an outpatient clinic session. Briefly discuss each patient seen by your learners,
and ask which screening tests should be considered and when for each.

Ideas and Opinions

This commentary discusses how patients in adult hospitals could benefit from the health
care approach found in pediatric wards, which includes being sensitive to stress-inducing
procedures and offering novel programs involving music, unique life specialists, and
nonpharmacologic techniques that seek to calm and uplift the spirit.

Use this study to:

Discuss with your learners what patient-centered care looks like. Have them make a
list of things they feel “compelled” to do in their daily work that
do not meet the criteria of patient-centeredness. Explore the pressures that influence
non–patient-centered behavior. Can your learners envision an adult hospital
experience that more closely resembles that described for pediatrics?

A 48-year-old man is evaluated for watery bowel movements. The patient is having 8
to 12 watery bowel movements daily. Several days before the diarrhea began, the patient
went to an urgent care clinic with a sinus headache. He was diagnosed with bacterial
sinusitis and given a 7-day course of antibiotics. He was asked to return to the urgent
care center if he experienced any problems or did not improve. He says there was no
discussion of adverse effects or alternatives to antibiotic therapy. Stool assay is
positive for Clostridium difficile toxin.

Which of the following can be concluded about informed consent in this case?

A. Acceptance of the antibiotics fulfilled requirements for informed consent
B. Informed consent is only needed for invasive procedures
C. Informed consent only applies when signing a consent form
D. Informed consent was not properly obtained

Correct Answer
D. Informed consent was not properly obtained

Key Point
The three key elements of informed consent are: understanding of the proposed treatment,
understanding of alternatives to the proposed treatment, and understanding the risks
and benefits of both the treatment and the alternatives.

Educational Objective
Understand the principles of informed consent.

The principles of informed consent were not followed in this case. The three key elements
of informed consent are: understanding of the proposed treatment, understanding of
alternatives to the proposed treatment, and understanding the risks and benefits of
both the treatment and the alternatives. In this case, the patient says he was not
given either information about risks of antibiotics or alternative options. This calls
into question whether he received adequate information to give informed consent.

Informed consent applies to all health care decisions, not only to invasive procedures.
It requires an active dialogue around the three key elements.

Many practitioners obtain written informed consent for invasive procedures because
this entails documentation of consent, but it does not exempt physicians from having
a discussion of risks, benefits, and alternatives for all treatments that have the
potential to cause harm.